Professor of Otolaryngology - Head and Neck Surgery (Facial Plastic Surgery) at the Stanford University Medical Center

Otolaryngology - Head & Neck Surgery Divisions

Bio

Bio

Dr. Most graduated with High Honors from the University of Michigan in Ann Arbor. Subsequently he attended Stanford University School of Medicine, where he received a prestigious Howard Hughes Medical Institute Grant and was honored with the Dean's Award upon graduation. He completed an internship in General Surgery at Yale University School of Medicine before returning to the West Coast. Upon his return, he trained at the University of Washington in Department of Otolaryngology-Head and Neck Surgery, where he received the Lampkin Temporal Bone Dissection Award in 1998, and the awards from the Association for Research in Otolaryngology (ARO) in 1997, 1998, and 1999. In 2000 he joined the Physicians Research Training Committee of the ARO, the first resident to do so. After residency, he was selected for what was, at that time, one of the most competitive fellowships in Facial Plastic and Reconstructive Surgery, also at the University of Washington. He has authored over 100 articles, textbook chapters and reviews on the science and practice of Facial Plastic and Reconstructive Surgery. He was appointed Division Chief in Facial Plastic & Reconstructive Surgery at the University of Washington in 2002, a position he also has held at Stanford since his arrival here in 2006.

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Research & Scholarship

Current Research and Scholarly Interests

Division of Facial Plastic and Reconstructive Surgery-Research Program Summary

Evidence-based medicine in Facial Plastic SurgeryThe primary goal of this research program is to develop a higher standard of care for facial plastic surgery patients. The approach to this goal is two-fold. The first involves development of prospective studies that examine the efficacy of new or existing surgical techniques in facial plastic surgery. One clinical problem we have already begun to examine is nasal obstruction. Functional rhinoplasty techniques have been a mainstay of otolaryngology, and facial plastic surgery in particular, for decades. While many have attempted, with mixed success, to examine nasal function using quantitative measures, few prospective studies of quality of life have been performed. To this end, we have begun to examine prospectively various functional rhinoplasty techniques.

The second approach to development of a higher standard of care for our patients is the testing of various over-the-counter ‘cosmeceutical’ products. Generally, products that are touted as effective by industry have little or no clinical evidence to back up said claims. Two of these studies have been completed and have resulted in remarkable response from industry as well as the media. More importantly, these types of studies provide valuable information about product efficacy to physicians and patients alike.

Facial Nerve Recovery after InjuryFacial nerve injury after trauma or extirpative surgery can be devastating to patients. The Division seeks to develop a clinical and basic research program studying facial nerve recovery after such injuries. The basic research program within the Division will use a previously developed animal (mouse) model for facial nerve injury to examine the age-dependence of motor neuron survival in the facial nucleus and its correlation to facial nerve recovery. Furthermore, the role of apoptotic cell death in the facial nerve nucleus will be studied, with the hope that anti-apoptotic processes may aid in facial nerve recovery. The clinical research program will study quality of life issues in facial nerve injury patients.

Publications

All Publications

Systematic review and meta-analysis of venous thromboembolism in otolaryngology-head and neck surgeryHEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECKMoubayed, S. P., Eskander, A., Mourad, M. W., Most, S. P.2017; 39 (6): 1249-1258

Abstract

The paramedian forehead flap is considered the gold standard procedure to optimally reconstruct major defects of the nose, but this procedure generally requires 2 stages, where the flap pedicle is divided 3 weeks following the initial surgery to ensure adequate revascularization of the flap from the surrounding recipient tissue bed, which can cost a patient time out of work or away from normal social habits. It has previously been shown that the pedicle may be safely divided after 2 weeks in select patients where revascularization from the recipient bed was confirmed using intraoperative laser fluorescence angiography to potentially save the patient time and money.To demonstrate the cost-effectiveness of takedown of the paramedian forehead flap pedicle after 2 weeks using angiography with indocyanine green (ICG).Retrospective cohort study of all patients who underwent 2-week division of the forehead flap after nasal reconstruction. Patient, tumor, defect, and outcomes data were collected. Cost-minimization analysis was performed by comparing the overall costs of 2-week takedown with angiography to a hypothetical patient undergoing 3-week takedown without angiography.Two-week division of the forehead flap after nasal reconstruction.Cost-minimization analysis performed by calculating the total variable costs for a patient in our cohort vs costs to a theoretical patient for whom angiography was not performed and the pedicle was divided at the 3-week mark.A total of 22 patients were included (mean [SD] age, 70.3 [10.0] years; 8 women [36.4%] and 14 men [63.6%]). The selection criteria for 2-week division of the pedicle are a wound bed with at least 50% vascularized tissue present, partial-thickness defects, and absence of nicotine use. All were divided at the 2-week mark with no instances of flap necrosis. One patient had a squamous eccrine carcinoma histology before reconstruction, all other patients had basal cell carcinoma, squamous cell carcinoma, and melanoma. Cost-minimization analysis showed that the use of angiography with ICG results in cost savings of $177 per patient on average.Two-week takedown of select paramedian forehead flap patients can be performed safely with verification using angiography with ICG. Although this technology inherently adds cost, it is cost-effective, saving a total of $177 per patient.NA.

Abstract

Nasal septal deviation is a prevalent problem that can have significant quality of life ramifications. Septoplasty is commonly performed to provide qualitative and quantitative benefit to those with nasal obstruction owing to septal deviation. Although a standard, basic technique is often adequate for individuals with mild to moderate mid to posterior septal deviation, unique challenges arise with caudal septal deviation. Herein, multiple strategies that attempt to address anterior septal deviation are discussed. Anterior septal reconstruction has been shown to be a safe and effective means by which to address severe caudal septal deviation and long-term reduction in preoperative symptoms.

Abstract

By convention, a "deviated nose" is one in which the lower third is asymmetric with regard to the midline. The lower third of the nose is composed of the lower cartilages, as well as the dorsal and caudal nasal septum. Not only does the deviated nose cause a cosmetic deformity that is often disconcerting for patients, but it may also be associated with functional problems. Airway obstruction may result from a narrowed internal nasal valve in the middle third or from a deviated caudal septum in the lower third. The most common deviation involves both the middle and lower thirds and often requires addressing the underlying dorsal and caudal septum. The most effective technique to correct this type of deviation is the principle of extracorporeal septoplasty, either the traditional or modified, such as the anterior septal reconstruction (ASR) technique combined with the clocking suture. An isolated middle third deviation may be treated with a camouflage graft or a unilateral spreader graft. An isolated lower third deviation involving the septum should be treated with ASR. When an isolated lower third deviation only involves the lower cartilages, it may be corrected using suture techniques, cartilage division techniques, or grafting.

Abstract

The nasal midvault is an important consideration in rhinoplasty. This region is defined by the attachment of the upper lateral cartilages (ULCs) to the nasal bones superiorly and the cartilaginous septum medially. Inadequate management of the nasal midvault can have negative functional and aesthetic ramifications. Indications for midvault reconstruction in primary rhinoplasty include a narrow midvault, dorsal hump resection, a deviated midvault, and an asymmetric midvault, with an additional relative indication of zone 1 lateral wall insufficiency (LWI), defined as dynamic collapse of a weakened lateral nasal wall at the level of the ULC. Numerous techniques for midvault reconstruction have been described, dating back to Sheen's description of the spreader graft in the 1980s, which remains the gold standard for repair. Herein, the various indications for midvault reconstruction are described, along with a discussion of the most commonly used techniques for successful reconstruction.

Abstract

Understanding the mechanisms in nerve damage can lead to better outcomes for neuronal rehabilitation. The purpose of our study was to assess the effect of major histocompatibility complex I deficiency and inhibition of the classical complement pathway (C1q) on functional recovery and cell survival in the facial motor nucleus (FMN) after crush injury in adult and juvenile mice.A prospective blinded analysis of functional recovery and cell survival in the FMN after a unilateral facial nerve crush injury in juvenile and adult mice was undertaken between wild-type, C1q knockout (C1q-/-), and KbDb knockout (KbDb-/-) groups. Whisker function was quantified to assess functional recovery. Neuron counts were performed to determine neuron survival in the FMN after recovery.After facial nerve injury, all adult wild-type mice fully recovered. Juvenile mice recovered incompletely corresponding to a greater neuron loss in the FMN of juveniles compared with adults. The C1q-/- juvenile and adult groups did not differ from wild type. The KbDb-/- adults demonstrated 50% recovery of whisker movement and decreased cell survival in FMN. The KbDb-/- juvenile group did not demonstrate any difference from control group.Histocompatibility complex I plays a role for neuroprotection and enhanced facial nerve recovery in adult mice. Inhibition of the classical complement pathway alone does not affect functional recovery or neuronal survival. The alternative and mannose binding pathways pose alternative means for activating the final components of the pathway that may lead to acute nerve damage.

Abstract

The nose and the nasal airway is highly complex with intricate 3-dimensional anatomy, with multiple functions in respiration and filtration of the respired air. Nasal airway obstruction (NAO) is a complex problem with no clearly defined "gold-standard" in measurement. There are 3 tools for the measurement of NAO: patient-derived measurements, physician-observed measurements, and objective measurements. We continue to work towards finding a link between subjective and objective nasal obstruction. The field of evaluation and surgical treatment for NAO has grown tremendously in the past 4-5 decades and will continue to grow as we learn more about the pathophysiology and treatment of nasal obstruction.

Abstract

To compare the scar outcomes of two common incisions (inverted V and stair step) by using a validated scar-outcome instrument via a randomized clinical trial.Fifty-eight consecutive cases of external rhinoplasty were randomly divided into two groups according to the type of incision. These patients were followed-up for 1 year, and the columellar scar was analyzed by using the Stony Brook Scar Evaluation Scale (SBSES) and visual analog scale (VAS) scores by an independent reviewer.Of 58 patients, 28 received the inverted V and the rest received the stair-step incision. Thirty-four participants (58.6%) were women. The mean (standard deviation) age of the participants was 26.2 ± 6.6 years. After 1 month, the scar outcome was significantly better in patients with the stair-step incision (p = 0.001) by using the SBSES, but the same was not true after 1 year (p = 0.425). However, when the VAS instead of the SBSES was used to evaluate the scar, the inverted V received a better score after 12 months in this series (p = 0.005).Despite the better aesthetic outcome of the stair-step incision in the first month after the surgery, there was no significant difference between the two incisions after 1 year. However, in this series, when the VAS instead of the SBSES was used to evaluate the scar, the inverted V received a better score after 12 months.

Abstract

Septal perforations present a challenging dilemma for surgical intervention when medical therapy fails. Multiple techniques have been described in the literature to address perforations using numerous techniques; however, there have been varying rates of success and reproducibility reported. The use of a large, pericranial flap was previously described to repair large septal perforation. The objective of this case report is to describe the use of a pedicled pericranial flap in combination with intraoperative fluorescence angiography to quantify vascular perfusion. This article presents a 31-year-old man with an idiopathic, septal perforation measuring 1.7?×?1.7 cm who previously failed medical therapy and surgical repair. He underwent a combined, coronal incision and external rhinoplasty approach with a tunneled pericranial flap resulting in a successful repair. This case report illustrates robust reconstructive capability of pericranial flaps for repair of septal perforations, as well as the potential value of intraoperative fluorescence angiography in determining the likelihood of a successful outcome.

Abstract

Health insurance companies commonly require a trial of corticosteroid nasal spray prior to authorizing nasal surgery, even in patients with severe to extreme anatomical nasal obstruction, despite lack of data supporting such medical therapy.To provide a model for the comparative analysis of medical vs surgical treatment for nasal obstruction to help maximize health care benefit per dollar spent and to explore the cost-effectiveness of corticosteroid nasal spray in patients with severe to extreme nasal airway obstruction on Nasal Obstruction Symptom Evaluation (NOSE) scores.A cost-efficiency frontier economic evaluation was performed. The economic perspective was that of the health care third-party payer. Effectiveness data were obtained from NOSE score questionnaires in 179 patients. An incremental cost-effectiveness ratio was determined from the cost and efficacy data. Comparative treatment groups were medical therapy with corticosteroid nasal spray vs surgical therapy for nasal airway obstruction. The study was conducted between January 1, 2011, and December 30, 2013. The time horizon included 1, 2, and 5 years. Data analysis was completed June 1, 2015.The primary outcome was cost per quality-adjusted life-year (QALY). A modified Markov decision tree model was used. Costs were obtained from the Medicare 2015 physician fee schedule, and the mean was determined (owing to geographic disparity) along with wholesale and generic pharmaceutical pricing.Among 100 men and 79 women evaluated (mean [SD] age, 37.9 [12.9] years), surgical repair of severe nasal airway obstruction cost $6537 and produced a total of 1.15 QALYs at 1 year. Medical treatment involved a trial of corticosteroid nasal sprays, which cost $520 and produced a total of 1.03 QALYs. The surgical approach was markedly more effective but at greater short-term cost. In cases of extreme nasal obstruction, medical treatment cost $520.73 with 1.004 QALYs, demonstrating an incremental cost-effectiveness ratio (ICER) of $354?693 per QALY compared with no treatment. Conversely, surgical treatment cost $6536.64 and produced 1.136 QALYs, with an ICER of $45?633 compared with medical therapy. At 5 years, the ICER decreased from $45?634 to $8110 per QALY for surgical treatment of extreme nasal obstruction. The medical treatment ICER decreased from $354?693 per QALY at 1 year to $273?704 per QALY at 5 years. An ICER was performed and demonstrated a cost threshold of $50?554 per QALY for surgical treatment compared with $67?518 per QALY for medical treatment at 1 year for severe nasal obstruction. If the evaluation is extended to 5 years, surgical treatment cost $8984 per QALY compared with $52?571 per QALY for medical treatment. Owing to the improved effectiveness outcomes, greater cost savings per ICER was demonstrated in patients with extreme nasal obstruction.Surgical treatment for patients with severe to extreme anatomical nasal obstruction demonstrates increased short-term expense but is cost-effective in the long term. These data suggest that treatment with corticosteroid nasal spray in patients with documented severe to extreme anatomical nasal obstruction is unnecessary and results in a delay in treatment.NA.

Abstract

Currently, there is no validated quality-of-life instrument that evaluates both functional and aesthetic outcomes after rhinoplasty. The goal of this study was to develop and validate a comprehensive quality-of-life instrument to assess patient satisfaction with both functional and aesthetic outcomes after rhinoplasty.The study was designed as a prospective instrument validation study at a university-affiliated academic medical center. Inclusion criteria included patients with nasal obstructive symptoms, nasal aesthetic deformity, or both, who underwent functional and/or aesthetic rhinoplasty by a single surgeon between December 2014 and June 2015. A novel 10-item instrument (the Rhinoplasty Health Inventory and Nasal Outcomes [RHINO] scale) was developed to assess physical, mental, and social well-being after functional and/or aesthetic rhinoplasty. Instrument validation was performed by assessment of test-retest reliability, internal consistency reliability, construct validity, and concurrent validity.Twenty-two patients (10 males and 12 females) were enrolled. Mean age was 34.9 years (range: 18-67 years). All patients were followed for a minimum of 12 weeks (range: 12-23 weeks; mean: 16.5 weeks). Mean RHINO score was 51.4 ± 13.8 on the first preoperative evaluation and 51.7 ± 12.5 when repeated preoperatively on the day of surgery (r = 0.94; P < 0.001). Internal consistency demonstrated Cronbach's ? value of 0.74. Mean postoperative RHINO score was 84.7 ± 14.1 (mean difference from preoperative RHINO = 33.2 ± 18.9; P < 0.001).The RHINO instrument demonstrates robust reliability and validity in assessing patient-reported satisfaction with rhinoplasty outcomes.

Abstract

Dorsal hump reduction without adequate reconstitution of the midvault can often result in cosmetic or functional problems. One of the simplest techniques to avoid these problems is the use of the excess upper lateral cartilage to reconstruct the midvault (the spreader flap or autospreader). Herein we outline the history of the technique and present the specific indications and contraindications, as well as describe our method for achieving it successfully. Case studies are presented with the specific indications. Grafting alternatives to the spreader flap are also outlined. The spreader flap technique offers multiple advantages, including maximal use of local tissues, simplicity, and airway preservation. Disadvantages are the use of an external approach and the inability to use it alone in the presence of severe asymmetries.

Abstract

Evidence-based medicine has become increasingly prominent in the climate of modern day healthcare. The practice of evidence-based medicine involves the integration of the best available evidence with clinical experience and expertise to help guide clinical decision-making. The essential tenets of evidence-based medicine can be applied to both functional and aesthetic rhinoplasty. Current outcome measures in functional and aesthetic rhinoplasty, including objective, subjective, and clinician-reported measures, is summarized and the current data is reviewed.

Abstract

To report the long-term efficacy of a modified extracorporeal septoplasty technique in the treatment of anterocaudal septal deviations.Case series with chart review.Academic tertiary care medical center.Data were obtained by a retrospective review of patients treated by a single surgeon (S.P.M.) from December 2010 to April 2014. A total of 77 patients (52 male, 25 female) met inclusion criteria. The Nasal Obstruction Septoplasty Effectiveness (NOSE) scale and a visual analog scale (VAS) were administered to all patients preoperatively and at each postoperative visit. Statistical analysis was performed using a matched-pair t test comparing preoperative and postoperative NOSE and VAS scores. A recently described severity scale for nasal obstruction was applied to NOSE scores to demonstrate postoperative results.Average follow-up was 4.7 months. Average preoperative NOSE and VAS scores were 68.2 ± 17.4 and 7.2 ± 1.8, respectively, placing these patients in the "severe" symptoms classification. Average NOSE and VAS scores in the early postoperative period (1-3 months after surgery) were 21.1 ± 19.8 (P < .0001) and 2.1 ± 2.6 (P < .0001), respectively. Average NOSE and VAS scores in the late postoperative period (>3 months after surgery) were 15.8 ± 19.0 (P < .0001) and 1.4 ± 1.8 (P < .0001), respectively. Both early and late postoperative NOSE scores represented "mild" symptomatology.Anterior septal reconstruction represents a powerful method for correction of nasal valve stenosis resulting from severe anterocaudal septal deviations.

Abstract

The paramedian forehead flap is used to reconstruct medium to large nasal defects. The staged nature, with its vascular pedicle bridging the medial eyebrow to the nose, results in significant facial deformity. Earlier division lessens this morbidity.To quantify flap neovascularization 2 weeks after the initial flap transfer and to describe an algorithm for earlier division of the flap pedicle in select patient populations.We performed a prospective and retrospective study at the Ambulatory Surgery Center, Stanford University, Palo Alto, California, from October 14, 2014, through January 21, 2015. Patients with defects appropriate for paramedian forehead flap reconstruction had partial-thickness defects, vascularized tissue in more than 50% of the recipient bed, and no nicotine use. The patients underwent reconstructive surgery by a single surgeon from August 24, 2012, through September 12, 2014. Laser-assisted indocyanine green angiography was used for imaging before and immediately after the initial flap transfer, before pedicle division with the pedicle atraumatically clamped, and immediately after pedicle division and flap inset. Analysis of data and calculation of relative perfusion were performed using a postprocessing analysis toolkit.Perfusion was calculated using the analysis toolkit as the percentage of the area of interest relative to a predetermined reference point in normal peripheral tissue.We enrolled a total of 10 patients. The mean (SD) relative perfusion of the forehead donor site before flap transfer was 61.2% (3.4%); at initial flap transfer, 81.4% (50.2% [range, 31%-214%]) (P?=?.70 compared with measurement before flap transfer). The mean (SD) relative perfusion of the forehead donor site was 57.5% (21.2% [range, 32%-89%]) at the time of atraumatic pedicle clamping and 58.6% (32.4% [range, 16%-127%]) after pedicle division and flap inset (P?=?.85 compared with measurement before flap transfer). No flap failures or other complications were observed.In select patients (those meeting the inclusion criteria), division of the pedicle at 2 weeks after the initial flap transfer is safe. Earlier pedicle division and flap transfer reduces the duration of facial deformity for the patient.3.

Abstract

To report outcomes for reconstruction of the nasal ala using a bilobe flap in combination with an auricular cartilage graft.Case series with chart review.Academic tertiary care medical center.Data were obtained by a retrospective review of patients treated by a single surgeon (SPM) from January 2013 to December 2014. Patients were included who underwent reconstruction of the nasal ala using a bilobe flap in combination with an auricular cartilage graft. Clinical notes and postoperative photographs were reviewed to evaluate post-operative outcomes including flap viability, presence of iatrogenic lateral nasal wall insufficiency, alar retraction, and patient and surgeon reported satisfaction with aesthetic outcome.A total of 7 patients (3 male, 4 female) met inclusion criteria. Patient age ranged from 34 to 71 years (mean: 55 years). Follow-up time ranged from 1 to 12 months (mean: 6.3 months). All defects were located within 5 mm of the alar margin. Defect size ranged from 6 to 15 mm in largest diameter (average 11 mm). There were no incidences of flap loss, alar retraction, or iatrogenic lateral wall insufficiency, and all patients had results deemed aesthetically satisfactory by both the patient and surgeon.Defects of the nasal ala can be successfully reconstructed using a bilobe flap in combination with an auricular cartilage graft with excellent aesthetic and functional outcomes.

Abstract

Septal spurs are exceedingly common structural deformities that contribute to nasal obstruction and often require surgical correction. The posterior extension of the quadrangular cartilage (PEQC) and its relationship with septal spurs have not been previously examined. We seek to examine the anatomic and histologic relationship of the PEQC and concurrent septal spurs in patients undergoing septoplasty.Prospective cohort study.Facial plastic and rhinology center in tertiary hospital setting.Thirty patients with septal deviation are described in this series. The quadrangular cartilage and associated septal spur were removed en bloc from patients undergoing septoplasty. The length of the PEQC, the side of spur deviation, and the relationship of the PEQC to the spur (ipsilateral vs contralateral) were recorded.The mean length of the PEQC, beyond the bony-cartilaginous junction, was 30.06 ± 6.06 mm. The PEQC was present on the ipsilateral side of the spur deviation in all 30 patients (100%).At sites of septal spur formation, the quadrangular cartilage possesses an average 3-cm extension beyond its junction with the bony components of the septum. This cartilaginous extension is exclusively found on the same side of spur deviation. These findings have implications on our understanding of the ontogeny of commonly found septal spurs and deviations, as well as treatment strategies and cartilage graft harvesting.

Abstract

Lateral nasal wall insufficiency is a common problem with little consensus on optimal treatment.To assess the efficacy of radiofrequency (RF) thermotherapy for the treatment of lateral nasal wall collapse.A prospective randomized trial comparing RF thermotherapy with bone-anchored suspension technique (BAST) for lateral nasal wall collapse in 13 patients was conducted, with recruitment occurring between March 1, 2010, and February 28, 2012, and follow-up of 1 year. The setting was a tertiary care facial plastic and reconstructive surgery clinic at an academic hospital. Eligible patients had lateral nasal wall insufficiency and met study inclusion criteria.Participants were randomized to receive either BAST of the lateral nasal wall or RF thermotherapy to the lateral nasal wall.Outcomes were assessed 1, 3, 6, and 12 months after surgery using 2 subjective patient outcomes surveys (the Nasal Obstructive Symptom Evaluation and a visual analog scale) and a physician-derived assessment of lateral wall collapse.Significant improvements in symptom scores were seen postoperatively for both treatment arms, though more consistently in the radiofrequency group. One month postoperatively, the mean (SD) drop in NOSE scores was 52.5?±?22.2 and 51.7?±?26 (P?=?.96) for the BAST and RF groups, respectively. Similar results were noted at 6 and 12 months postoperatively (56.7?±?38.2 vs 50?±?14.7 [P?=?.76] and 53.3?±?20.2 vs 56.7?±?18.9 [P?=?.84] at 6 and 12 months, respectively). No statistical difference in change in NOSE scores occurred between the 2 groups at 1, 6, or 12 months postoperatively. Likewise, the drop in VAS scores between the 2 treatment groups was similar at each time point. One month postoperatively, the mean (SD) drop in VAS scores was 5.1?±?2.8 and 4.8?±?2.6 (P?=?.90). Similar results were noted at 6 and 12 months postoperatively (5.8?±?3.4 vs 4.9?±?3.1 [P?=?.72] and 5.5?±?3.1 vs 5.4?±?1.3 [P?=?.96] at 6 and 12 months, respectively). Using a physician-derived score, significant improvement was seen in patients in the RF group at 1 month (P?=?.005), 6 months (P?=?.002), and 12 months (P?=?.03). For the BAST group, significant improvement was noted only at the 1-month postoperative visit (P?=?.007). Comparison of RF vs BAST revealed significant improvement in the RF group over the BAST group at 12 months (P?=?.04). The other periods revealed no significant differences between the two.Radiofrequency thermotherapy is a viable alternative option for lateral nasal wall collapse, both in terms of improvements in symptoms and physical examination, with suggested evidence for efficacy at least as good as that for bone-anchored suspension.1.isrctn.org Identifier: ISRCTN14219489.

Abstract

Internal nasal valve collapse is a preventable complication of rhinoplasty, for which the spreader graft is the gold standard. More recently, the spreader flap technique has been espoused as an alternative to spreader grafting. Here, we evaluated the efficacy of this technique in a randomized trial setting.The autospreader was used in 32 patients who were candidates for primary rhinoplasty; 34 who did not undergo a spreader flap procedure were recruited as a control group. Acoustic rhinometry was used in every patient preoperatively and 1 year postoperatively. Average volume and minimal cross-sectional area (MCA) of the nose and findings were collected. Also, the pre- and postoperative patients' subjective assessment about their satisfaction from their appearance and nasal obstruction were evaluated according to visual analog scale (VAS).Among the study group patients, 46 (69.7%) were female and 20 (30.3%) were male subjects. Their mean age was 50/5 ± 6/24 years. The difference in MCA in the control group was -0.1 and +0.6 (on right and left sides, respectively), and in the spreader flap group it was -0.03 and +0.05, which showed an increase in MCA in the left side and a decrease in the opposite side of both groups. However, their difference was not statistically significant (p = 0.50). Also, the differences between preoperative and postoperative VAS were not significant in either nasal obstruction (p = 0.68) and cosmetic satisfaction (p = 0.38).Spreader flap is an attractive technique in preserving the middle vault in nasal plastic surgery. However, its effect needs more evaluation.

Abstract

This article provides a concise description of common complications of rhinoplasty, recommendations for avoidance, and corrective techniques. The surgeon must have a comprehensive understanding of nasal anatomy and effects of surgical maneuvers to help avoid complications. Meticulous history, physical examination, and standardized photographic documentation are central to preoperative evaluation and surgical planning for rhinoplasty. Photographic documentation is useful to illustrate preexisting preoperative asymmetries. Appropriate preoperative counseling regarding appropriate postoperative expectations as well as all risks, benefits, and alternatives is critical. Any complications should be openly discussed with the patient.

Abstract

IMPORTANCE Nasal airway obstruction is a common presenting symptom in otolaryngology and facial plastic surgery practices, and the potential for multiple contributing causes requires extensive evaluation. OBJECTIVE To develop a classification system for nasal obstruction using a subjective, validated quality-of-life instrument. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of patients' responses on the Nasal Obstruction Symptom Evaluation (NOSE) instrument performed from July 2011 through May 2012. All patients were seen at a university-based tertiary medical center. MAIN OUTCOMES AND MEASURES Scores from patients with or without nasal obstruction were used to develop a classification system after receiver operating characteristic curve analysis. The classification subdivides nasal obstruction scores into a range of defined classes. RESULTS Data analysis was performed using results from 345 patients. A score of 30 on the NOSE survey best differentiated patients with and without nasal obstruction. This threshold also provided intervals used to define the other class ranges. Patients were categorized as having mild (range, 5-25), moderate (range, 30-50), severe (range, 55-75), or extreme (range, 80-100) nasal obstruction, depending on responses on the NOSE survey. CONCLUSIONS AND RELEVANCE The NOSE scale is an important tool for gauging symptoms in patients with nasal obstruction. The proposed classification system will improve patient care by providing a framework for the severity of their symptoms and helping them understand potential treatment effects. If the classification is used in future outcomes research, it will allow physicians to better understand the study patient population and the effect of treatment on each severity class. LEVEL OF EVIDENCE NA.

Abstract

In the cochlear nucleus (CN), the first central relay of the auditory pathway, the survival of neurons during the first weeks after birth depends on afferent innervation from the cochlea. Although input-dependent neuron survival has been extensively studied in the CN, neurogenesis has not been evaluated as a possible mechanism of postnatal plasticity. Here we show that new neurons are born in the CN during the critical period of postnatal plasticity. Coincidently, we found a population of neural progenitor cells that are controlled by a complex interplay of Wnt, Notch, and TGF?/BMP signaling, in which low levels of TGF?/BMP signaling are permissive for progenitor proliferation that is promoted by Wnt and Notch activation. We further show that cells with activated Wnt signaling reside in the CN and that these cells have high propensity for neurosphere formation. Cochlear ablation resulted in diminishment of progenitors and Wnt/?-catenin-active cells, suggesting that the neonatal CN maintains an afferent innervation-dependent population of progenitor cells that display active canonical Wnt signaling.

Abstract

This study was designed to validate a grading scheme for lateral nasal wall insufficiency with interrater and intrarater reliability measures. Representative endoscopic videos depicting varied degrees of lateral nasal wall insufficiency were collated into a 30-clip video (15 clips in duplicate). This was rated by five reviewers for a total of 150 observations. Interrater and intrarater reliability were determined using Fleiss kappa and intraclass correlation coefficient (ICC) statistics, respectively. Good agreement was established between reviewers (interrater reliability), with a Fleiss kappa of 0.7733 (p < 0.01). Analysis of intrarater variability with the ICC revealed a very strong agreement (ICC = 0.88; p < 0.01). The proposed grading system is shown to have good interrater and intrarater reliability. It provides a reliable instrument for assessing lateral wall insufficiency.

Abstract

Blepharoplasty is one of the most commonly performed aesthetic procedures in the realm of aging face surgery. Although not prohibitively challenging from a technical perspective, upper blepharoplasty remains a surgical procedure that requires comprehensive knowledge of intricate eyelid anatomy. In addition, the surgeon must pay attention to adjacent areas, notably the brow, which may also need to be addressed to achieve optimal results. These features, along with changes associated with aging and important aspects of the clinical evaluation are reviewed herein. A thorough history and physical exam are required, along with a frank discussion of the patient's expectation and the surgeon's ability to address them. The authors' approach to preoperative marking and surgical procedure are included, along with discussion of variations in technique. Complications that may be seen after upper blepharoplasty are also discussed.

Abstract

This study was designed to measure the efficacy of a nasal valve suspension technique and determine the adequate traction length without creation of nasofacial fullness in a cadaveric model. Seven fresh frozen cadaveric heads were evaluated. Minimal cross-sectional (MCA) areas were measured with a transient-signal acoustic rhinometer (Ecco Vision; Hood Instruments, Pembroke, MA) before and after suspension. The adequate traction length, which did not cause obvious changes, was determined. Five millimeters of lateral nasal valve traction was determined to be the maximal traction achievable without creating facial fullness. After lateral nasal suspension, average MCA increased by 13.7%. Average distance to the MCA from the nostril changed from 1.57 to 1.76 cm. Postsuspension values were significantly higher than the presuspension values (p < 0.05). Nasal valve suspension with 5 mm of lateral traction has a significant impact on nasal valve area without obvious nasofacial changes.

Abstract

To quantify the perfusion of forehead flaps and compare blood flow from the supratrochlear artery with vascular in-growth at the recipient bed.Patients with nasal defects necessitating forehead flap closure were prospectively enrolled to study flap perfusion dynamics. Laser-assisted indocyanine green angiography was used to obtain the measurements. When possible, patients returned for weekly recording of flap perfusion from the recipient bed with the pedicle clamped. Analysis of the data was performed using SPY-Q software.Six patients were prospectively enrolled. All patients had intraoperative angiography at flap transfer, pedicle division, and at least 1 postoperative visit between these surgical procedures. Flow was measured as a percentage of perfusion of normal surrounding tissue. A higher percentage of perfusion was seen at the distal end of the flap when compared with the pedicle when the pedicle was clamped. This phenomenon was seen as early as the 1-week postoperative visit.This is the first study attempting to quantify forehead flap perfusion from the supratrochlear artery and recipient bed. Data obtained suggest evidence of vascular in-growth 1 week following flap transfer.

Abstract

Overresection of the lateral crura of the lower lateral cartilages is referred to as the most common cause of nasal valve collapse after rhinoplasty. The modern approach to functional rhinoplasty recognizes the importance of the tip framework's structural integrity and preserves tip support.Traditional cephalic resections of lateral crura were performed on one side of five adult cadaver noses. On the opposite sides, hinged flaps of lateral crura were created. The noses were cross-sectioned at or near the internal nasal valve level, and the difference between the two sides was described.The study findings demonstrated improvement in the postoperation nasal valve area of the hinged flap side compared with the cephalic trim side.This preliminary study showed that the hinged flap is an option in nasal tip reduction surgery that may provide improved long-term aesthetic and functional outcomes through preservation of the nasal valve area.

Abstract

To measure the efficacy of a specific midvault reconstruction technique (the autospreader flap) in dorsal reductive rhinoplasty with a validated quality-of-life instrument.A prospective observational outcomes study of patients desiring reduction of the nasal dorsum who either (1) had no breathing obstruction, who underwent purely aesthetic rhinoplasty, or (2) had concomitant severe nasal obstruction due to septal deviation, internal valve narrowing, and/or turbinate hypertrophy, who subsequently underwent combined functional and aesthetic rhinoplasty. Preoperative and postoperative evaluation was performed using the Nasal Obstruction Symptoms Evaluation (NOSE) scale.Thirty-eight patients completed preoperative and postoperative evaluation. No complications occurred. Patients in the purely aesthetic group were noted to have low preoperative NOSE scores, with no change postoperatively. There was a significant improvement in mean NOSE score postoperatively for the combined functional and aesthetic group (P < .001).Midvault reconstruction using the autospreader graft may help prevent postoperative nasal obstruction due to midvault collapse. Combining this procedure with dorsal reduction in functional rhinoplasty patients with traditional airway reconstruction techniques is effective in improving nasal airway function as measured by a patient-based, disease-specific quality-of-life instrument.

Abstract

To evaluate the correlation between growth differences of the face and nasal septal deviation, and to evaluate whether developmental differences of the face have an effect on nontraumatic nasal septal deviation (DNS).Retrospective study.Twenty-five patients with DNS who underwent facial aesthetic surgery and had an ostiomeatal unit-computed tomography (OMU-CT) scan and photos for facial analysis were included in the study. Coronal views of the OMU-CT scan where the nasal septum was most severely deviated were selected and from which five parameters (angle of septal deviation [ASD], angle of nasal floor [ANF], angle of lateral nasal wall [ALW], angle of inferior turbinate [AIT], and width of IT [WIT]) were measured. Preoperative frontal views of the patients were analyzed by comparing the distances between the following points on both sides of the faces: midsagittal plane to Zygion (MSP-Zy), Glabella to Exocanthion (G-Ex), Exocanthion to Cheilion (Ex-Ch), and Zygion to Cheilion (Zy-Ch).The differences between the right and left MSP-Zy, G-Ex, and Ch-Zy distance were significantly associated with the direction of septal deviation. The difference between the right and left AIT and WIT were also significantly associated with the direction of septal deviation. Using bivariate correlation, it was found that the absolute difference between the right and left MSP-Zy, G-Ex, and WIT showed significant correlation with the amount of septal deviation.We demonstrate that there is a strong relationship between deviated nasal septum and facial growth asymmetry.

Abstract

To assess the effects of corticosteroid administration on functional recovery and cell survival in the facial motor nucleus (FMN) following crush injury in adult and juvenile mice and to evaluate the relationship between functional recovery and facial motoneuron survival.A prospective blinded analysis of functional recovery and cell survival in the FMN after crush injury in juvenile and adult mice was carried out. All mice underwent a unilateral facial nerve crush injury and received 7 doses of daily injections. Adults received normal saline or low-dose or high-dose corticosteroid treatment. Juveniles received either normal saline or low-dose corticosteroid treatment. Whisker function was monitored to assess functional recovery. Stereologic analysis was performed to determine neuron and glial survival in the FMN following recovery.Following facial nerve injury, all adult mice recovered fully, while juvenile mice recovered slower and incompletely. This corresponded to a significantly greater neuron loss in the FMN of juveniles compared with adults. Corticosteroid treatment slowed functional recovery in adult mice. This corresponded with significantly greater neuron loss in the FMN in corticosteroid-treated mice. In juvenile mice, corticosteroid treatment showed a trend, which was significant at several time points, toward a more robust functional recovery compared with controls.Corticosteroid treatment slows functional recovery and impairs neuron survival following facial nerve crush injury in adult mice. The degree of motor neuron survival corresponds with functional status. In juvenile mice, crush injury results in overall poor functional recovery and profound cell loss in the FMN. With low-dose corticosteroid treatment, there is a significantly enhanced functional recovery after injury in these mice (P < .05).

Abstract

The field of stem cell biology has undergone tremendous expansion over the past two decades. Scientific investigation has continued to expand our understanding of these complex cells at a rapidly increasing rate. This understanding has produced a vast array of potential clinical applications. This article will serve as an overview of the current state of stem cell research as it applies to scientific and medical applications. Included in the discussion is a review of the many different types of stem cells, including but not limited to adult, embryonic, and perinatal stem cells. Also, this article describes somatic cell nuclear transfer, an exciting technology that allows the production of totipotent stem cells from fully differentiated cells, thereby eliminating the use of embryonic sources. This discussion should serve as a review of the field of stem cell biology and provide a foundation for the reader to better understand the interface of stem cell technology and facial plastic and reconstructive surgery.

Abstract

Zygomatic-maxillary (ZMC) complex fractures are a common consequence of facial trauma. In this retrospective study, we present a novel method of ZMC fracture pattern analysis, utilizing three-dimensional visualization of computed tomography (CT) images to record displacement of the malar eminence in a three-dimensional coordinate plane. The pattern of fracture was then correlated with treatment outcome. Facial CT scans were obtained from 29 patients with unilateral ZMC fractures and 30 subjects without fractures and analyzed. Briefly, displacement of the malar eminence (ME) on the fractured side was measured in medial-lateral (x), superior-inferior (y), and anterior-posterior (z) dimensions, as well as Euclidean distance, by comparison to ME location on the unfractured side. Baseline natural variance in asymmetry was accounted for by comparing ME location on the left and right sides in subjects without fractures. Patients who required open reduction and internal fixation (ORIF) to repair the ZMC fracture alone had significantly greater cumulative ME displacements than patients who did not require ORIF (p?=?0.02). Additionally, patients with a high fracture score of 3, 4, or 5 (assigned based on severity displacement in each dimension) had significantly higher rates of ORIF than patients with a low fracture score of 0, 1, or 2 (p?=?0.05). Severe displacement in one or more dimensions was associated with higher rates of ORIF than seen in patients with only neutral or mild displacements in all dimensions (p?=?0.05). Severe x displacement was most strongly correlated with surgical intervention (p?=?0.02). Overall, orbital floor repair was less strongly associated with most displacement measures than ZMC repair alone; however, patients requiring orbital floor repair had greater Euclidean ME displacements than patients who did not require orbital floor repair (p?=?0.02). Fracture severity, as determined by multiple parameters in this novel evaluation system, is associated with higher rates of ORIF in patients with unilateral ZMC fractures. Determination of ZMC fracture pattern may thus be informative when considering treatment options.

Abstract

To examine use of the paramedian forehead flap for intranasal lining.The medical records and photographs were reviewed for patients who underwent a nasal reconstruction involving a paramedian forehead flap used for internal lining.Three patients underwent this procedure. In all patients, the flap provided excellent intranasal lining. External incisions were acceptable in all the patients.The paramedian forehead flap may be used for internal lining of large intranasal defects. An external rhinoplasty approach facilitates reconstruction.

Abstract

The eyes are the most captivating feature of the face. Many of the early signs of aging occur in the periocular region. This article focuses on surgical rejuvenation of the upper eyelid with an emphasis on the eyelid anatomy, aging of the eyes, clinical evaluation, surgical technique, and postoperative complications. The paradigm has shifted to a more conservative resection of skin, muscle, and fat to preserve fullness to the upper eyelid that portrays youthfulness.

Abstract

Photodocumentation in facial plastic surgery is essential in the perioperative setting, and with meticulous uniformity and standardization it serves as the primary tool for surgical planning and critical analysis of results. Accurate photodocumentation is dependent on strict and consistent use of equipment, lighting, and patient positioning. The purpose of this article is to review the principles of standardization in perioperative patient photography for common facial plastic procedures and to provide the facial plastic surgeon with the tools necessary to develop consistent and accurate patient photographs.

Abstract

The art and technology of photography can be overwhelming to the facial plastic surgeon. Photographic documentation of patients undergoing rhinoplasty is essential for patient consultation, perioperative planning, and postsurgical evaluation. Possession of a basic understanding of photographic principles, technique, equipment, as well as consideration regarding consistency of patient positioning is essential for producing the best photographic results. This article reviews the basic principles of photography and discusses their application to facial plastic surgery practice, and rhinoplasty in particular.

Abstract

Volume measurements calculated from axial and coronal CT scans were compared to determine which method more accurately determines orbital volume.Thirty facial CT scans were used to measure 30 normal orbits using an image analysis program (Dextroscope, Singapore). The 3-dimensional volumes determined from axial scans and coronal scans were analyzed. The coronal scan volume measurements were further subdivided based on anterior limit criteria (termed C1 and C2). Three novel cephalometric angular measurements of the anterior orbital aperture were calculated and used to analyze the volumetric methodologies described above.The calculated orbital volume was greatest on axial scan, 25.6 +/- 2.4 ml, followed by volume based on coronal calculations with C1 delimitation (23.8 +/- 2.9 ml) and C2 delimitation (16.6 +/- 2.2 ml). We measured 3 novel orbital aperture angles on sagittal 3-dimensional reconstruction images, anterovertical, posterovertical, and horizontal orbital aperture angles that are related to the volume measurement underestimation.The orbital volume from coronal scans is underestimated compared with that from the axial scans, and the criterion for anterior limit of measurement can affect volume determination. Three novel cephalometric angle measurements may account for inaccuracies in orbital volume measurements.

Abstract

To measure the orbital volume of unilateral pure blowout fractures with computed tomography before and after surgery and to compare 3-dimensional (3-D) imaging systems.Twenty-four patients were evaluated with facial computed tomographic scans before and after surgery. Both the orbital volume and the displaced soft tissue volume were measured by 2 operators using 2 different 3-D software programs (Vitrea; Vital Images Inc, Minnetonka, Minnesota; and Dextroscope; Bracco AMT Inc, Princeton, NJ).The mean (SD) normal orbital volumes calculated by Vitrea and Dextroscope were 25.5 (2.4) mL and 24.8 (3.0) mL, respectively. The average preoperative orbital volumes were 28.3 (2.3) mL and 27.6 (3.1) mL, while the postoperative volumes were 25.8 (2.5) mL and 24.9 (3.0) mL. Vitrea showed that the average volume of displaced orbital soft tissue was 2.8 (1.9) mL before surgery and that it was reduced to 0.3 (1.3) mL after surgery, while Dextroscope showed that the average displaced orbital soft tissue was 2.9 (1.4) mL before surgery and that it was reduced to 0.1 (1.2) mL after surgery. There was no statistical difference between the 3-D analysis programs.Consistent volume measurements can be obtained using different 3-D image analysis programs. Measuring preoperative and postoperative volume changes and postoperative reduction can ensure a good surgical result and thereby decrease the incidence of enophthalmos.

Abstract

To study the outcome of patients with orbital apex lesions treated with endoscopic decompression alone.Retrospective medical chart review with a mean follow-up of 25.6 months.Departments of Ophthalmology and Otolaryngology, University of Washington, Seattle.Five individuals seen at the University of Washington Medical Center from November 2003 through December 2005 with visual disturbance caused by orbital apex lesions as documented by preoperative magnetic resonance imaging or computed tomographic scan.All patients underwent endoscopic decompression of the medial wall of the orbital apex with incision of the periorbita.Postoperative visual acuity, presence or absence of a relative afferent pupillary defect, color vision, and visual field were recorded.All 5 patients presented with visual field deficits, 4 of whom improved postoperatively. Three patients had dyschromatopsia preoperatively, 2 of whom improved postoperatively. Visual acuity improved or stabilized in 4 of 5 patients postoperatively. One patient had progressive visual loss during the course of her follow-up, which, after obtaining postoperative imaging, was attributed to inadequate decompression of the apex at its most posterior aspect. This same patient also developed postoperative sinusitis that resolved with antibiotic treatment. Two patients developed diplopia, 1 in primary gaze requiring treatment with prismatic lenses. All patients presented with and maintained normal intraocular pressures.Orbital apex lesions can often be effectively and relatively safely treated by endoscopic decompression alone.

Abstract

To determine the efficacy of an over-the-counter topical skin adhesive pad for reducing central forehead and glabellar rhytids over a 4-week period.Prospective series involving 30 healthy volunteers with central forehead and glabellar rhytids at a tertiary care academic medical center. The participants used topical skin adhesive pads over the central forehead area and the glabella for 4 weeks in an effort to reduce rhytids. Before and after treatment, the participants had facial photographs taken and completed a questionnaire assessing the severity of their rhytids. Blinded to the timing of the photographs, 2 independent facial plastic surgeons scored the pretreatment and posttreatment rhytid severity using the Glogau scale (1-4) and a wrinkle severity scale (1-10) to evaluate treatment effect.Twenty-six participants (87%) completed follow-up with an average of 7.4 hours of use of the topical adhesive pads per night. The independent evaluators found minimal improvements in the Glogau scores (mean [SD], 0.12 [0.33] [P = .08] and 0.06 [0.22] [P = .18] for the central forehead area and the glabella, respectively). The same evaluators also found minimal change in the wrinkle severity scores (mean [SD], 0.21 [1.28] [P = .41] and 0.25 [0.75] [P = .10] out of 10 for central forehead rhytids and glabellar rhytids, respectively). None of these measures were statistically significant. The study participants' self-evaluations demonstrated changes in the wrinkle severity scores of 0.35 (2.10) (P = .41) in the central forehead area and 0.73 (1.7) (P = .04) in the glabella.Subjective self-evaluation of topical adhesive pads demonstrates improvement in glabellar rhytids but may be affected by bias. Independent, blinded evaluation by facial plastic surgeons showed no statistical benefit in the reduction of rhytids in the central forehead area or the glabella.

Abstract

The sequelae of trauma to the nose include nasal deformity and nasal obstruction that can have a long-term negative impact on patient quality of life. Successful management of posttraumatic nasal obstruction relies on a detailed history, careful analysis, and accurate diagnosis. Dividing the nose into horizontal thirds assists in preoperative analysis as well as surgical treatment. Adequate treatment of posttraumatic nasal obstruction must address deflection of the bony nasal pyramid, septal deformities (especially caudal or dorsal), turbinate hypertrophy, and incompetence of internal and external nasal valves. Treatment must balance the seemingly disparate goals of re-establishing structure, improving contour and esthetics, as well as restoring the nasal airway.

Abstract

Age-related changes in the structure of the nose can obstruct the nasal airway and adversely affect quality of life. Several procedures are available to restore the patency of the airway, but not all are appropriate for all patients. Also, long-term outcomes data on such procedures are lacking. We describe our use of a rhinolift procedure with local anesthesia to correct nasal obstruction caused by nasal tip ptosis in 2 elderly men. In both cases, the procedure resulted in a complete or near-complete resolution of obstructive symptoms. We also conducted long-term follow-up of these 2 patients. Both experienced a recurrence of symptoms 1 to 2 years postoperatively. We conclude that the rhinolift procedure we describe is safe and effective for the short-term relief of age-related nasal obstruction in selected patients.

Abstract

Resection of the alar cartilage has long been a mainstay of aesthetic rhinoplasty. One drawback of this technique is the destabilization of the ala/lateral nasal wall complex. Herein we describe the cephalic turn-in flap, a technique for reinforcement of the alar cartilage after removal of its cephalic portion.

Abstract

The perioperative period can be anxiety provoking for rhinoplasty patients. Patients rely on the skill and confidence of the surgeon to attain optimal results. Having an established strategy for the preoperative, anesthetic, and postoperative care of this patient population is critical to achieving a successful outcome and to ensuring a positive experience for the patient. Establishing a sincere rapport in the preoperative period and being able to properly address patient concerns regarding anesthesia helps patients develop a positive frame of mind and aids in their recovery. This presentation reviews important elements of the preoperative, anesthetic, and postoperative care of rhinoplasty patients and provides insight to making the experience a positive one for the patient and the surgeon.

Abstract

Rejuvenation of the lower eyelid blepharoplasty in men requires consideration of different esthetic norms than those considered in women. Although both require a thorough understanding of anatomy, and the process of aging in each includes descent of the globe, pseudoherniation of the orbital fat, and skeletonization of the inferior bony rim, the goals for male blepharoplasty differ. The authors review the primary surgical approaches in lower lid blepharoplasty (transconjunctival skin-muscle flap) and the currently described techniques used to address displaced orbital fat, with special consideration of the male patient.

Abstract

The variety and complexity of periorbital surgical procedures continue to increase. Successful completion of reconstructive and esthetic ocular procedures requires an exacting knowledge of the relevant anatomy. Interestingly, the definition of ocular and periorbital anatomy continues to evolve, including more recent descriptions of the orbitomalar ligament and a new understanding of eyelid lymphatics. This article presents the most recent descriptions of periorbital anatomy.

Abstract

To determine the safety and efficacy of using porous high-density polyethylene (PHDPE) in the repair of orbital defects.Retrospective case series.Academic tertiary care trauma center. Patients One hundred seventy patients with orbital defects requiring surgical repair. Intervention Orbital defect repair with PHDPE. Main Outcome Measure Our review documents surgical results and complications associated with the use of PHDPE.There was a 6.4% complication rate associated with the use of PHDPE. The infection rate was 1.8%. The persistent orbital malposition rate was 3.5%. The extrusion rate was 0%.This report represents the largest case series in the literature using PHDPE for orbital reconstructions. The use of PHDPE resulted in a low complication rate and excellent functional and cosmetic reconstructive results. Because of our success with the use of PHDPE, we have changed our clinical practice to minimize the use of autologous graft material, thereby eliminating donor site morbidity in cases involving orbital reconstruction.

Abstract

A thorough understanding of the anatomy of the nose is paramount in rhinoplasty. Correction of deformities of the nasal vault presents a challenge to the facial plastic surgeon. Suboptimal aesthetic results may occur when either inadequate or excessive mobilization of the nasal bony-cartilaginous framework is performed. Furthermore, postoperative complications such as collapse of the nasal airway may occur. A number of techniques are available to appropriately mobilize and reposition the bony nasal vault. In this article, we will review pertinent anatomy, technical considerations and clinical perspectives on mobilization of the nasal bones.

Abstract

To develop a mouse model for measuring facial nerve injury and recovery and to test the hypothesis that overexpression of the antiapoptotic gene, bcl2, enhances recovery of facial nerve function after peripheral crush injury.Prospective analysis of recovery of function after facial nerve crush injury in mice at juvenile (postnatal day 7) and adult (postnatal day 30) ages with blind comparison of wild-type and transgenic bcl2 overexpression littermates at both ages and immunohistologic confirmation of overexpression of bcl2 in facial motoneurons in transgenic animals.Adult wild-type mice demonstrated full recovery of facial nerve function (measured as eye blink and whisker movement) within 3 weeks of injury. Juvenile wild-type mice demonstrated diminished recovery of function. Juvenile transgenic bcl2 overexpression mice demonstrated more rapid and complete recovery of eye blink but not whisker movement in comparison with wild-type littermates.Measurement of facial nerve function in mice after injury is feasible. Enhanced recovery of facial nerve function in adult mice and mice overexpressing bcl2 indicates that preservation of central motoneurons after injury may improve function after peripheral nerve injury.

Abstract

The Abble flap is a full-thickness composite flap, involving the transfer of the skin, muscle, and mucosa of the central part of the lover lip to the upper lip. This vermilionpedicled flap, based on the inferior labial vessels, has been used for secondary corrections in cleft deformities, more often in bilateral cases. Indications for its use include deficiency of scarring of the central part of the upper lip. thinness of the vermilion with a nonexistent lip tuberculum, or the absence of a Cupid's bow. The procedure may be combined with other reconstructive procedures.

Abstract

Facial cosmetic procedures lend themselves to outcomes studies in ways that traditional reconstructive procedures may not. The most important measures of outcome in facial cosmetic surgery are quality of life and patient satisfaction, in contrast to other, more objective measures such as complications or mortality rates. For this reason, outcomes research in facial cosmetic surgery deserves a special focus of attention. In this article, we review outcomes studies for the more common facial cosmetic procedures, discuss in depth what aspects of patient-related satisfaction have been quantified by these existing studies, and highlight the direction that future outcomes research projects may wish to follow. There exists an abundance of potential interesting areas of study in facial cosmetic surgery, and the application of outcomes research methodology to these realms may allow the facial plastic surgeon to better define the success or failure of each individual facial cosmetic surgery procedure.